What is the peritonsillar abscess?

Peritonsillar abscess refers to the accumulation and suppuration of pus between the tonsillar capsule and the pharyngeal constrictor muscle.¹ It’s the most common deep infection of the head and neck.

Peritonsillar abscess is diagnosed in patients of almost all age groups but mostly affects young adults (15–19 years), with an incidence of 167 new cases per 100,000 population. It is also common in children and adolescents, especially people assigned male at birth (AMAB).²

Most peritonsillar abscesses occur unilaterally (on one side of the throat), and they rarely affect the patient bilaterally (on both sides).

With this article, we are aiming to provide you with a comprehensive insight into the treatment and prevention of peritonsillar abscesses. We will briefly discuss the causes, risk factors, symptoms and diagnosis, to help you to recognise the problem earlier and seek appropriate medical attention.

Causes and risk factors of peritonsillar abscess?

• Peritonsillar abscess is considered to be a common complication of acute tonsillitis, where bacteria invade the surrounding tissues from the tonsillar mucosa³
• It may also occur due to infection of the minor salivary glands or from Weber’s salivary gland -salivary glands located in the upper soft palate
• Poor oral hygiene, periodontal diseases and smoking have been associated with peritonsillar abscesses, by promoting tissue damage, but with an unclear mechanism of action

Symptoms

Symptoms of peritonsillar abscess are:

• Fever
• Sore throat
• Trismus (restriction of jaw movement)
• Bulging, oedema, redness and stiffness of the soft palate
• Odynophagia (painful swallowing)
• Voice changes
• Ear pain
• Drooling of saliva

Diagnosis

Diagnosis of peritonsillar abscess starts with taking a detailed history from the patient, including asking about symptoms like pain, fever and difficulty swallowing. Secondly, a physical examination should be done to detect the signs of peritonsillar abscess.

A thorough history and clinical examination can often lead to a diagnosis of peritonsillar abscess, but additional tests may help differentiate it from other diseases.

These tests include:

• Ultrasound⁴
• Computed Tomography (CT) scan
• Needle aspiration

Treatment

There are multiple treatment options for peritonsillar abscesses, which can be divided into medical and surgical categories.

Medical management

• Antibiotic therapy

The type of antibiotic prescribed depends on the type of bacteria that caused the infection. This may be discovered by running a culture and sensitivity test, which can detect the responsible bacteria and show which antibiotics it should respond to.⁵

Penicillin has traditionally been the antibiotic of choice for treating Peritonsillar abscesses, but the emergence of beta-lactamase-producing organisms, which are resistant to penicillins, may affect this choice.

• Pain control

Over-the-counter painkillers, such as Ibuprofen or paracetamol, can help relieve pain and fever in those with peritonsillar abscesses.

• Hydration and rest

Intravenous rehydration may be part of supportive treatment for peritonsillar abscesses. Plenty of rest is also necessary to help the body fight the infection.

The use of medical management alone may be appropriate and beneficial in selected patients, while in others it’s necessary to perform additional surgical management.

Surgical management

• Incision and Drainage

Local anaesthesia is administered first, using a lidocaine solution, and then a 1 cm incision is performed with a scalpel at the upper lateral side of the tonsils.

Incision and drainage are considered more effective in cases where there is a large amount of pus, but it’s more painful and requires hospitalisation postoperatively (after the procedure).⁶

• Needle aspiration (NA)

Needle aspiration is a simple procedure that is performed by insertion of a needle in the most protruded part of the swelling, followed by aspiration of the pus collection. It has an advantage over incision and drainage as it’s more easily performed and manipulated, has lower cost and has a high success rate, though it has also been found that it has insufficient drainage and recurrence is considered a potential risk.⁷

• Tonsillectomy

Tonsillectomy is a complete removal of tonsils, in which general anaesthesia is required.  Postoperative haemorrhage is a rare but possible complication, and the procedure is riskier in patients with coagulation disorders and those on long-term anticoagulation therapy.⁸

Tonsillectomy is considered a definitive treatment of peritonsillar abscess as it provides complete drainage and removes the wall of the abscess, significantly reducing the chances of recurrence. However, it possesses a higher risk of bacteremia and subsequent spreading of the bacteria than other surgical management options.

After completion of the treatment, the doctor will schedule a follow-up appointment to monitor the patient’s progression and ensure that adequate healing is taking place.

Postoperative instructions

After treatment of peritonsillar abscess patients should be advised to:

• Stay hydrated
• Avoid hot food and drinks that could irritate the throat
• Eat a soft diet that is easy to swallow
• Take enough rest to allow the body to heal and fight the infection
• Gargle with warm salt water several times a day, to  promote healing
• Avoid smoking and the consumption of alcohol
• Be aware of the complications such as pain, swelling and difficulty breathing
• Contact a healthcare provider if they have any concerns and follow the instructions correctly to ensure healing

Prevention of peritonsillar abscess

Prevention of peritonsillar abscesses involves a reduction of the chances of developing tonsillitis, which is the main risk factor for peritonsillar abscesses. Advice includes:

• Practising good oral hygiene by brushing the teeth twice daily to prevent the spread of the bacteria into the tonsils
• Avoid sharing your items with others, especially those with respiratory infections and contagious diseases
• Maintain a healthy lifestyle by getting enough sleep, staying hydrated, exercising and eating a balanced diet
• Avoid smoking, which increases the risk of developing tonsillitis
• Immediately seek medical help to treat tonsillitis, if it occurs, to reduce the likelihood of complications

Potential risks of peritonsillar abscess

There is a wide range of complications that may arise due to untreated peritonsillar abscess, which varies from one patient to another.

These complications may include:

Upper airway obstruction due to the large size of the abscess

• Acute epiglottitis
• Necrotising fasciitis
• Parotid gland and other spaces abscess
• Descending mediastinitis
• Lung infection
• Brain abscess
• Septic arthritis

Summary

Peritonsillar abscess refers to the accumulation and suppuration of pus between the tonsillar capsule and the pharyngeal constrictor muscle. It’s the most common deep infection of the head and neck. Prevention of peritonsillar abscesses involves a reduction of the chances of developing tonsillitis, which is the main risk factor for peritonsillar abscesses. Recognise the symptoms of peritonsillar abscess and immediately seek medical help. Try to lead a healthy lifestyle and form a good habit.